CA2092703C - Arterial co2 monitor and closed loop controller - Google Patents
Arterial co2 monitor and closed loop controllerInfo
- Publication number
- CA2092703C CA2092703C CA002092703A CA2092703A CA2092703C CA 2092703 C CA2092703 C CA 2092703C CA 002092703 A CA002092703 A CA 002092703A CA 2092703 A CA2092703 A CA 2092703A CA 2092703 C CA2092703 C CA 2092703C
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- Prior art keywords
- patient
- paco2
- deadspace
- breath
- ratio
- Prior art date
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B5/00—Measuring for diagnostic purposes; Identification of persons
- A61B5/08—Detecting, measuring or recording devices for evaluating the respiratory organs
- A61B5/091—Measuring volume of inspired or expired gases, e.g. to determine lung capacity
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B5/00—Measuring for diagnostic purposes; Identification of persons
- A61B5/08—Detecting, measuring or recording devices for evaluating the respiratory organs
- A61B5/083—Measuring rate of metabolism by using breath test, e.g. measuring rate of oxygen consumption
- A61B5/0836—Measuring rate of CO2 production
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
- A61M16/00—Devices for influencing the respiratory system of patients by gas treatment, e.g. mouth-to-mouth respiration; Tracheal tubes
- A61M16/0051—Devices for influencing the respiratory system of patients by gas treatment, e.g. mouth-to-mouth respiration; Tracheal tubes with alarm devices
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
- A61M16/00—Devices for influencing the respiratory system of patients by gas treatment, e.g. mouth-to-mouth respiration; Tracheal tubes
- A61M16/021—Devices for influencing the respiratory system of patients by gas treatment, e.g. mouth-to-mouth respiration; Tracheal tubes operated by electrical means
- A61M16/022—Control means therefor
- A61M16/024—Control means therefor including calculation means, e.g. using a processor
- A61M16/026—Control means therefor including calculation means, e.g. using a processor specially adapted for predicting, e.g. for determining an information representative of a flow limitation during a ventilation cycle by using a root square technique or a regression analysis
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
- A61M2230/00—Measuring parameters of the user
- A61M2230/20—Blood composition characteristics
- A61M2230/202—Blood composition characteristics partial carbon oxide pressure, e.g. partial dioxide pressure (P-CO2)
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- Health & Medical Sciences (AREA)
- Life Sciences & Earth Sciences (AREA)
- Pulmonology (AREA)
- Veterinary Medicine (AREA)
- Heart & Thoracic Surgery (AREA)
- Public Health (AREA)
- General Health & Medical Sciences (AREA)
- Animal Behavior & Ethology (AREA)
- Engineering & Computer Science (AREA)
- Biomedical Technology (AREA)
- Emergency Medicine (AREA)
- Surgery (AREA)
- Medical Informatics (AREA)
- Molecular Biology (AREA)
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- Physics & Mathematics (AREA)
- Anesthesiology (AREA)
- Hematology (AREA)
- Obesity (AREA)
- Measurement Of The Respiration, Hearing Ability, Form, And Blood Characteristics Of Living Organisms (AREA)
- Investigating Or Analysing Biological Materials (AREA)
- Measuring Pulse, Heart Rate, Blood Pressure Or Blood Flow (AREA)
Abstract
The arterial CO2 monitor and closed loop controller for use with a ventilator mo nitors a patient's breath and determines PaCO2 based upon a determination of a deadspace ratio, which is the r atio of the alveolar deadspace to alveolar tidal volume. The method generally comprises the steps of continuously monitoring meas urable parameter of a patient's breath; obtaining an input value of PaCO2 from a blood sample of the patient and using t he patient's breath parameters and the input value to calculate the deadspace ratio; and continuously determining PaCO2 based on the assumption that the dead-space ratio subsequently remains constant. Decision rules obtained from oth er measurable data are preferably also used to identify the onset of changes in the deadspace ratio, and a new deadspace ratio is then determined from the patient's breath parameters and further input value of PaCO2 from the patient's blood sample.
Description
927~
BACKGROUND OF THE INVENTION
Field of the Invention:
This invention related to a method and apparatus for continuously and non-invasively monitoring arterial blood CO2 partial pressure (PaCO2) of artificially ventilated patients.
Description of Related Art:
Mechanical ventilation is required by patients in an intensive care unit who are unable to control their own respiration. The rate of ventilation must be adjusted so that arterial CO2 is within a desirable range.
Conventionally clinicians adjust the ventilator settings based on periodically drawn blood samples. In order to monitor rapidly changing PaCO2 (for monitoring or closed loop control purposes), a continuous and non-invasive monitor is desirable. Known transcutaneous transducers are non-invasive but require heating of the patient's skin to 44~C and a long stabilization time of 30 minutes which renders them unsatisfactory for continuous monitoring. The known method of assuming a constant arterial to end-tidal CO2 di-~erence is not reliable during ventilation/perfusion changes, and attempts to implement closed loop ventilation control have failed largely due to the inability to continuously and non-invasively observe the variable to be controlled, that is, the PaCO2 .
Thus, the direct methods of monitoring PaCO2 are invasive, and indirect methods are not reliable, particularly because end-tidal CO2 is influenced by deadspace, which is an unmeasurable quality.
I~
SUBSTITUTE SHEET
-W092/0486~ PCT/AU91/00435 2u92703 It would thus be desirable to provide a method and apparatus for providing a continuous and substantially non-invasive PaCO2 estimation.
SUMMARY OF THE INVENTION
Briefly, and in general terms the invention provides a method and apparatus for continuously and non-invasively monitoring arterial blood CO2 partial pressure (PaCO2) of artificially ventilated patients, by monitoring a patient's breath and determining PaCO2 based upon a determination of a deadspace ratio, which is the ratio of the alveolar deadspace to alveolar tidal volume. The method generally comprises the steps of continuously monitoring measura~le parameters of a patient's breath;
obtaining an input value of PaCO2 from a blood sample of -15 the patient and using the patients breath parameters and the input value to calculate the deadspace ratio; and continuously determining PaCO2 based on the assumption that the deadspace ratio subsequently remains constant.
Decision rules obtained from other measurable data are preferably also used to identify the onset of changes in the deadspace ratio, and a new deadspace ratio is then determined from the patient's breath parameters and a further input value of PaCO2 from the patient's blood sample.
The determination of PaCO2 is preferably based upon the equation VD~ PaC~2 ~ PE C~2 =
VT~ PaC~2 ~ PiC~2 where VD~ is the alveolar deadspace, VT~ is the alveolar tidal volume, P~CO2 is the mixed-expired CO2 from the alveolar tidal volume, and SUBSTIT-JTE SHEFr W092/~86~ PCT/AU91/0043~
_ 3 _ 2092703 .
PiCO2 is inspired CO2.
The mixed-expired CO2, inspired CO2, alveolar tidal volume and the alveolar deadspace are the measurable para-~eters or the patient's breath.
The other measurable data used to determine decision rules for identifying changes in the deadspace ratio are preferably related to lung mechanics and trends in CO2 production.
The method preferably further involves adjusting patient ventilation based on the determined value of PaCO2 .
In another aspect of the invention, an apparatus is provided for continuously and non-invasively monitoring arterial blood CO2 partial pressure (PaCO2) of artificially ventilated patients. The apparatus preferably includes a capnograph for monitoring - continuously measurable parameters relevant to a patient's breath and providing data relating thereto, and means for determining a deadspace ratio connected to the capnograph to receive the breath parameter data and adapted to receive information relating to the PaCO2 of a blood sample of the patient based upon the PaCO2 information and the breath parameter data. Means are also preferably provided for continuously determining PaCO2 based on the deadspace ratio, and the assumption that the deadspace ratio remains subsequently constant.
However, means are also preferably provided for further receiving decision rules enabling identification of the onset of changes in the deadspace ratio to thereby signal the need for a further blood sample to re-calculate the deadspace ratio.
The apparatus is preferably connected to a mechanical ventilator to control operation of the - ventilator based on the values of PaCO2 determined by the apparatus.
These and other aspects and advantages of the invention will become apparent from the following SUBSTITUTE SHEET
W O 92/04865 P(~r/AU91/00435 2 ~ 9 L2, 'I IJ ~
detailed description, and the accompanying drawings, which illustrate by way of example the features of the invent ion.
BRIEF DESCRIPTION OF THE DRAWINGS
FIGURE 1 is a basic functional block diagram of the apparatus of the invention;
FIGURE 2 is a block diagram in the form of a software flow chart for the apparatus of Figure l;
FIGURE 3 is a graph of airwave CO2 partial pressure versus expired volume for each breath of the patient;
FIGURE 4 is a schematic diagram showing the main method steps according to the invention;
FIGURE 5 is a graph of test results showing PaCO2 estimation; and FIGURES 6(A) and 6(B) show a detailed functional block diagram of the apparatus of the invention.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
In Figure 1 the outlet port of capnograph 10 is connected, via connection 11, to analogue to digital (A/D) converter 12. The capnograph 10 may, for example, be a HP-78356 and the A/D converter 12 may comprise analogue devices such as an RTl-815.
The A/D converter 12 is connected via connections 13 and 14 to computer 15 which may, for example, be an IBM compatible PC-AT286. The connection 13 is to the interrupt port of the computer 15 and the connection 14 is to the data port.
SUB~ I 11 ~JTE SHEET
W092/~865 PCT/AU9l/0043~
20927~3 A mechanical ventilator 16 such as a Puritan-Bennett 7200 is typically connected both to ~he A/D
converter 12 and the computer 15 as shown. The connections 17 and 18 are to the analogue ports of the ventilator and carry signals related to the pressure and flow respectively. The connection 19 is to the digital port of the ventilator 16 and provides an RS-232 link to the computer 15.
Referring now to Figure 4, the method in fact involves two major modules, the first of which is the PaC02 estimator 20 and the second of which is the decision module 21. The estimation module 20 receives information on input 22 related to measurements taken from each breath of patient 23, that is, by a breath-by-breath analysis. The decision module 21 receivesinformation on input 24 obtained from other measurable - quantities relevant to the patient such as lung mechanics and trends in C02 production for example, and contains decision rules obtained by previous experimentation. The rules are implemented as the rule-base of an Expert system.
The PaC02 estimator 20 is described by equation (1) .
VD~ PaC02 - PEC02 (1) VT~ PaC~2 ~ PiC~2 where VD~ is the alveolar deadspace, VT~ is the alveolar tidal volume, PEC02 is the mixed-expired CO2 from the alveolar tidal volume, and PiCO2 is inspired CO2.
The deadspace ratio is the ratio of alveolar deadspace to alveolar tidal volume.
The various parameters may be obtained from the plot of airwave C02 partial pressure versus expired volume for each breath a shown in the single breath test graph SUB~ JTE SHEE~
W092/~86~ PCT/AU91/0043 ~og27 ~3 - 6 -of Figure 3. On the graph PEICO2 is end tidal CO2, and VT
is tidal volume involved in gas exchange. The alveolar deadspace (represented by area Y) is that part of inspired gas which reache~ the alvecli but does not take part in gas exchange. VD'~, the airway deadspace, is the point of maximum inflection of the plot. From Figure 1, PECO2 and PiCo2 may be found using Equation (2) - (5).
PE-CO2 = areaX/VT (2) PiCo2 = PECO2 - P~ ~CO2 (3) PEb~CO2 = P~ CO2 * VT/VI
PEh~CO2 = VCo2 * 863 VT * f where f is the respiratory rate. VCO2 is carbon dioxide production which can be calculated each minute by integrating the CO2 fraction (FCO2 ) and the flow signal, as shown in Equation (6) - (7).
. 1 min VCO2 = ~ V * FCO2 (6) k = 1 FCO2 = PCO2 (7) P~ Y + PB + PH20 where V is flow, FCO2 is fraction of CO2, PCO2 is the capnograph signal, PUW~ is airway pressure, PB is barometric pressure and PH20 is vapor pressure.
Breath-by-breath processing yields the mixed-expired CO2, inspired CO2, alveolar tidal volume and the airway deadspace. The only unknowns being PaCO2 obtained after a blood sample analysis, the deadspace ratio can be calculated. Assuming that the deadspace ratio remains subsequently constant, further PaCO2 can be calculated using Equation (1). A PaCO2 estimate is calculated once SUB~ JTE SHEET
W092/04865 PCT/AU91/0043~
~ ~ 7 - ~0~2~3 every minute based on the average of the breaths in the minute.
Certain corrections are needed when implementing the system as ~et forth below:
s (a) Flow signals have to be corrected form BTPS (Body Temperature Pressure Saturated) to STPD (Standard Temperature Pressure Dry).
(b) Correction must be made for delay-time between the flow signals and capnograph signals. Delay time is found by simple breath-holding and rapid expiration through the airway tubing, and lining up the start of flow and capnograph signals.
(c) Correction for compliance of the airway tubing.
Flow due to compliance volume is subtracted form the analog flow signal, using _dP C = V, d' where P = airway pressure, C = tubing compliance, - V = flow due to compliance.
(d) Correction for rebreathing is done by continuously integrating flow and CO2 fraction, using Equation (6).
(e) Correction of capnograph signal for vapor pressure and airway pressure is done by Equation (7)-As mentioned above the decision rules are obtained by experimentations to determine rules which indicate a change in the deadspace ratio whereby the system may signal that a new blood test is reguired.
The following are the decision rules derived:
(i) If Alveolar minute volume increases and CO2 production decreases, deadspace ratio may - have changed.
(ii) If Alveolar minute decreases and CO2 production increases, deadspace ratio may have changed.
SlJ-Bs 111 ~JTE SHEEl' W092/04865 PCT/AU91/0043~
(iii) If Alveolar minute volume increases and - arterial or end-tidal CO2 increases, deadspace may have changed.
(iv) If Alveolar minute volume decreases and arterial or end-tidal CO2 decreases, deadspace may have changed.
It is possible to derive further rules to indicate a change in deadspace ratio. For example, changes to airway resistance, peak airway pressure (PAP), peak flow, SaO2 , inspiratory to expiratory ratio, and positive end-expiratory pressure (PEEP) should indicate a change in the deadspace ratio. By automatically recording these parameters during a clinical trial, including blood test results, correlation between the lS change in parameters and change in deadspace ratio can be performed.
If desired, a closed-loop control of ventilation may be implemented based on the predicated PaCO2 . The controller in this case is a set of rules which decides on the tidal volume and respiratory rate settings for the mechanical ventilator, to achieve and maintain PaCO2 at a set-point. The controller rules are based on existing clinical protocol for ventilator settings.
The control algorithm is presented below:
First, a PaCO2 setpoint has to be determined as follows:
Given the pH value from the most recent blood gas result, if pH is between 7.36 and 7.44, the PaCO2 setpoint is 40 mm Hg, the default value. If pH exceeded the limits, the following equation is used to calculate a new PaCO2 setpoint.
pH = 6.l + log (HCO3-/(0.03 * PaCO2)) where pH = 7.4, and HCO3- is from the most recent blood gas analysis results. The PaCO2 setpoint can also be set by the clinician, overriding the above calculations.
Next, ventilation settings for the next 5 minutes can be set by the following equation.
SUB~i 111 ~JTE SHEET
W O 92/04865 PC~r/A U91/0043~
9 2~927(~3 PCO2 * (VT * f ) = PaC02 * (VT~ * f') where PaC02 is the setpoint, (VT~ * f) is the alveolar minute ventilation needed to achieve the setpoint, PaC02 is the latest estimation, ~nd (YT~ * f') is the latest minute ventilation.
To decide on the actual VT and f, from the minute volume, the following procedures are followed:
Increase VT and keep f constant, so that ( 1) VT is not smaller then 500 ml.
(2) VT is not bigger than 1000 ml.
BACKGROUND OF THE INVENTION
Field of the Invention:
This invention related to a method and apparatus for continuously and non-invasively monitoring arterial blood CO2 partial pressure (PaCO2) of artificially ventilated patients.
Description of Related Art:
Mechanical ventilation is required by patients in an intensive care unit who are unable to control their own respiration. The rate of ventilation must be adjusted so that arterial CO2 is within a desirable range.
Conventionally clinicians adjust the ventilator settings based on periodically drawn blood samples. In order to monitor rapidly changing PaCO2 (for monitoring or closed loop control purposes), a continuous and non-invasive monitor is desirable. Known transcutaneous transducers are non-invasive but require heating of the patient's skin to 44~C and a long stabilization time of 30 minutes which renders them unsatisfactory for continuous monitoring. The known method of assuming a constant arterial to end-tidal CO2 di-~erence is not reliable during ventilation/perfusion changes, and attempts to implement closed loop ventilation control have failed largely due to the inability to continuously and non-invasively observe the variable to be controlled, that is, the PaCO2 .
Thus, the direct methods of monitoring PaCO2 are invasive, and indirect methods are not reliable, particularly because end-tidal CO2 is influenced by deadspace, which is an unmeasurable quality.
I~
SUBSTITUTE SHEET
-W092/0486~ PCT/AU91/00435 2u92703 It would thus be desirable to provide a method and apparatus for providing a continuous and substantially non-invasive PaCO2 estimation.
SUMMARY OF THE INVENTION
Briefly, and in general terms the invention provides a method and apparatus for continuously and non-invasively monitoring arterial blood CO2 partial pressure (PaCO2) of artificially ventilated patients, by monitoring a patient's breath and determining PaCO2 based upon a determination of a deadspace ratio, which is the ratio of the alveolar deadspace to alveolar tidal volume. The method generally comprises the steps of continuously monitoring measura~le parameters of a patient's breath;
obtaining an input value of PaCO2 from a blood sample of -15 the patient and using the patients breath parameters and the input value to calculate the deadspace ratio; and continuously determining PaCO2 based on the assumption that the deadspace ratio subsequently remains constant.
Decision rules obtained from other measurable data are preferably also used to identify the onset of changes in the deadspace ratio, and a new deadspace ratio is then determined from the patient's breath parameters and a further input value of PaCO2 from the patient's blood sample.
The determination of PaCO2 is preferably based upon the equation VD~ PaC~2 ~ PE C~2 =
VT~ PaC~2 ~ PiC~2 where VD~ is the alveolar deadspace, VT~ is the alveolar tidal volume, P~CO2 is the mixed-expired CO2 from the alveolar tidal volume, and SUBSTIT-JTE SHEFr W092/~86~ PCT/AU91/0043~
_ 3 _ 2092703 .
PiCO2 is inspired CO2.
The mixed-expired CO2, inspired CO2, alveolar tidal volume and the alveolar deadspace are the measurable para-~eters or the patient's breath.
The other measurable data used to determine decision rules for identifying changes in the deadspace ratio are preferably related to lung mechanics and trends in CO2 production.
The method preferably further involves adjusting patient ventilation based on the determined value of PaCO2 .
In another aspect of the invention, an apparatus is provided for continuously and non-invasively monitoring arterial blood CO2 partial pressure (PaCO2) of artificially ventilated patients. The apparatus preferably includes a capnograph for monitoring - continuously measurable parameters relevant to a patient's breath and providing data relating thereto, and means for determining a deadspace ratio connected to the capnograph to receive the breath parameter data and adapted to receive information relating to the PaCO2 of a blood sample of the patient based upon the PaCO2 information and the breath parameter data. Means are also preferably provided for continuously determining PaCO2 based on the deadspace ratio, and the assumption that the deadspace ratio remains subsequently constant.
However, means are also preferably provided for further receiving decision rules enabling identification of the onset of changes in the deadspace ratio to thereby signal the need for a further blood sample to re-calculate the deadspace ratio.
The apparatus is preferably connected to a mechanical ventilator to control operation of the - ventilator based on the values of PaCO2 determined by the apparatus.
These and other aspects and advantages of the invention will become apparent from the following SUBSTITUTE SHEET
W O 92/04865 P(~r/AU91/00435 2 ~ 9 L2, 'I IJ ~
detailed description, and the accompanying drawings, which illustrate by way of example the features of the invent ion.
BRIEF DESCRIPTION OF THE DRAWINGS
FIGURE 1 is a basic functional block diagram of the apparatus of the invention;
FIGURE 2 is a block diagram in the form of a software flow chart for the apparatus of Figure l;
FIGURE 3 is a graph of airwave CO2 partial pressure versus expired volume for each breath of the patient;
FIGURE 4 is a schematic diagram showing the main method steps according to the invention;
FIGURE 5 is a graph of test results showing PaCO2 estimation; and FIGURES 6(A) and 6(B) show a detailed functional block diagram of the apparatus of the invention.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
In Figure 1 the outlet port of capnograph 10 is connected, via connection 11, to analogue to digital (A/D) converter 12. The capnograph 10 may, for example, be a HP-78356 and the A/D converter 12 may comprise analogue devices such as an RTl-815.
The A/D converter 12 is connected via connections 13 and 14 to computer 15 which may, for example, be an IBM compatible PC-AT286. The connection 13 is to the interrupt port of the computer 15 and the connection 14 is to the data port.
SUB~ I 11 ~JTE SHEET
W092/~865 PCT/AU9l/0043~
20927~3 A mechanical ventilator 16 such as a Puritan-Bennett 7200 is typically connected both to ~he A/D
converter 12 and the computer 15 as shown. The connections 17 and 18 are to the analogue ports of the ventilator and carry signals related to the pressure and flow respectively. The connection 19 is to the digital port of the ventilator 16 and provides an RS-232 link to the computer 15.
Referring now to Figure 4, the method in fact involves two major modules, the first of which is the PaC02 estimator 20 and the second of which is the decision module 21. The estimation module 20 receives information on input 22 related to measurements taken from each breath of patient 23, that is, by a breath-by-breath analysis. The decision module 21 receivesinformation on input 24 obtained from other measurable - quantities relevant to the patient such as lung mechanics and trends in C02 production for example, and contains decision rules obtained by previous experimentation. The rules are implemented as the rule-base of an Expert system.
The PaC02 estimator 20 is described by equation (1) .
VD~ PaC02 - PEC02 (1) VT~ PaC~2 ~ PiC~2 where VD~ is the alveolar deadspace, VT~ is the alveolar tidal volume, PEC02 is the mixed-expired CO2 from the alveolar tidal volume, and PiCO2 is inspired CO2.
The deadspace ratio is the ratio of alveolar deadspace to alveolar tidal volume.
The various parameters may be obtained from the plot of airwave C02 partial pressure versus expired volume for each breath a shown in the single breath test graph SUB~ JTE SHEE~
W092/~86~ PCT/AU91/0043 ~og27 ~3 - 6 -of Figure 3. On the graph PEICO2 is end tidal CO2, and VT
is tidal volume involved in gas exchange. The alveolar deadspace (represented by area Y) is that part of inspired gas which reache~ the alvecli but does not take part in gas exchange. VD'~, the airway deadspace, is the point of maximum inflection of the plot. From Figure 1, PECO2 and PiCo2 may be found using Equation (2) - (5).
PE-CO2 = areaX/VT (2) PiCo2 = PECO2 - P~ ~CO2 (3) PEb~CO2 = P~ CO2 * VT/VI
PEh~CO2 = VCo2 * 863 VT * f where f is the respiratory rate. VCO2 is carbon dioxide production which can be calculated each minute by integrating the CO2 fraction (FCO2 ) and the flow signal, as shown in Equation (6) - (7).
. 1 min VCO2 = ~ V * FCO2 (6) k = 1 FCO2 = PCO2 (7) P~ Y + PB + PH20 where V is flow, FCO2 is fraction of CO2, PCO2 is the capnograph signal, PUW~ is airway pressure, PB is barometric pressure and PH20 is vapor pressure.
Breath-by-breath processing yields the mixed-expired CO2, inspired CO2, alveolar tidal volume and the airway deadspace. The only unknowns being PaCO2 obtained after a blood sample analysis, the deadspace ratio can be calculated. Assuming that the deadspace ratio remains subsequently constant, further PaCO2 can be calculated using Equation (1). A PaCO2 estimate is calculated once SUB~ JTE SHEET
W092/04865 PCT/AU91/0043~
~ ~ 7 - ~0~2~3 every minute based on the average of the breaths in the minute.
Certain corrections are needed when implementing the system as ~et forth below:
s (a) Flow signals have to be corrected form BTPS (Body Temperature Pressure Saturated) to STPD (Standard Temperature Pressure Dry).
(b) Correction must be made for delay-time between the flow signals and capnograph signals. Delay time is found by simple breath-holding and rapid expiration through the airway tubing, and lining up the start of flow and capnograph signals.
(c) Correction for compliance of the airway tubing.
Flow due to compliance volume is subtracted form the analog flow signal, using _dP C = V, d' where P = airway pressure, C = tubing compliance, - V = flow due to compliance.
(d) Correction for rebreathing is done by continuously integrating flow and CO2 fraction, using Equation (6).
(e) Correction of capnograph signal for vapor pressure and airway pressure is done by Equation (7)-As mentioned above the decision rules are obtained by experimentations to determine rules which indicate a change in the deadspace ratio whereby the system may signal that a new blood test is reguired.
The following are the decision rules derived:
(i) If Alveolar minute volume increases and CO2 production decreases, deadspace ratio may - have changed.
(ii) If Alveolar minute decreases and CO2 production increases, deadspace ratio may have changed.
SlJ-Bs 111 ~JTE SHEEl' W092/04865 PCT/AU91/0043~
(iii) If Alveolar minute volume increases and - arterial or end-tidal CO2 increases, deadspace may have changed.
(iv) If Alveolar minute volume decreases and arterial or end-tidal CO2 decreases, deadspace may have changed.
It is possible to derive further rules to indicate a change in deadspace ratio. For example, changes to airway resistance, peak airway pressure (PAP), peak flow, SaO2 , inspiratory to expiratory ratio, and positive end-expiratory pressure (PEEP) should indicate a change in the deadspace ratio. By automatically recording these parameters during a clinical trial, including blood test results, correlation between the lS change in parameters and change in deadspace ratio can be performed.
If desired, a closed-loop control of ventilation may be implemented based on the predicated PaCO2 . The controller in this case is a set of rules which decides on the tidal volume and respiratory rate settings for the mechanical ventilator, to achieve and maintain PaCO2 at a set-point. The controller rules are based on existing clinical protocol for ventilator settings.
The control algorithm is presented below:
First, a PaCO2 setpoint has to be determined as follows:
Given the pH value from the most recent blood gas result, if pH is between 7.36 and 7.44, the PaCO2 setpoint is 40 mm Hg, the default value. If pH exceeded the limits, the following equation is used to calculate a new PaCO2 setpoint.
pH = 6.l + log (HCO3-/(0.03 * PaCO2)) where pH = 7.4, and HCO3- is from the most recent blood gas analysis results. The PaCO2 setpoint can also be set by the clinician, overriding the above calculations.
Next, ventilation settings for the next 5 minutes can be set by the following equation.
SUB~i 111 ~JTE SHEET
W O 92/04865 PC~r/A U91/0043~
9 2~927(~3 PCO2 * (VT * f ) = PaC02 * (VT~ * f') where PaC02 is the setpoint, (VT~ * f) is the alveolar minute ventilation needed to achieve the setpoint, PaC02 is the latest estimation, ~nd (YT~ * f') is the latest minute ventilation.
To decide on the actual VT and f, from the minute volume, the following procedures are followed:
Increase VT and keep f constant, so that ( 1) VT is not smaller then 500 ml.
(2) VT is not bigger than 1000 ml.
(3) Peak airway pressure (PAP) is not greater than 40.
If (2) or (3) cannot be satisfied, keep VT constant and increase f such that -(a) f is not smaller than 10 bpm.
(b) f is not bigger than 20 bpm. (and not less than 10 bpm.) (c) Inspiratory to expiratory ratio (I:E) is smaller than 1:2.
If (b) or (c) is exceeded, Peak air flow (PAF) should be increased.
If the required minute volume cannot be achieved without exceeding the limits in any one of VT/f/PAP/mean pressure/PAF/I:E, a warning message will be displayed to alert the clinician.
As is evident above, the system of the invention is implemented, according to one embodiment, on a PC-AT
computer. Analogue flow and pressure signals from the Puritan-Bennett 7200 ventilator and airwave CO2 signals from the HP-78356 capnograph are analogue-to-digital converted and processed in real time using the computer.
Each breath is checked to reject unphysiological waveforms, such as incomplete spontaneous breaths, before further processing. A PaCO2 estimate is calculated every minute and the decision rules are invoked.
Tests have been performed to verify all calculations made in formulating the decision rules. C02 SUBSTITUTE ~;HEET
production and mixed-expired CO2 were tested against the Douglas bag method. Airway deadspace was checked by introducing a known deadspace into the ventilator circuit. Correct,ons had to be made to account for airway tubing compliance, time delay between the flow and capnograph signal, and rebreathing. To test the accuracy of PaCO2 estimation, clinical trials were carried out on ICU patients. For each patient, tidal volume and ventilation rate were changed in different combinations to a maximum of 30% of the initial settings. After each change and a stabilization period of about 10 minutes, a blood sample was drawn to check the estimation. Each clinical experiment involved 6-8 manipulations, over 90 minutes.
To identify the factors and the degree that they affect the alveolar deadspace ratio, specific procedures are incorporated into the clinical experiments to change the deadspace. Posture of the patient is changed by tuning the patient or inclining of the bed. Another procedure has been to administer bronchodilators.
Various measurable parameters are recorded during the experiments for correlation with deadspace changes.
These include airway compliance and resistance, peak airway pressure, peak air flow, inspiratory time, positive end-expiratory pressure (PEEP), inspiratory to expiratory ratio (I:E), slope of the CO2 versus expired-volume waveform, end-tidal CO2 and SaO2.
The test results show reliable estimation (+ 5 mmHg) of PaCO2, even when deadspace ratio changed by up to 30% of the initial value. This indicates that the estimator is robust to some changes in the deadspace ratio.
Test results also showed that deadspace ratio change can be expected when alveolar tidal volume and ~5 frequency changes are not followed by expected changes in end-tidal CO2, estimated PaCO2 or CO2 production. Results from a trial are presented in Fig. S. At point A, the SUBSTITUTE SHEET
increase in alveolar tidal volume and ventilation rate product (alveolar minute-volume) is not followed by a drop in both end-tidal CO2 and estimated PaCO2, indicating a blood test is needed. At point B, alveolar minute-5 volume decrease is not followed by an increase in end-tidal CO2. In each case, the new estimation system correctly identifies the deadspace ratio change and estimates PaCO2 reliably, compared to using the traditional method based on a constant arterial - end tidal difference.
Changes to compliance and resistance, peak airway pressure, peak flow, SaO2 and I:E should indicate a change in the deadspace ratio but more results are needed before these relationships can be quantified.
The results show that the PaCO2 estimator is sufficiently robust to permit continuous estimation for a wide range of ventilator settings. For large deadspace changes, the experimentally derived rules can be relied upon to signal for a blood gas test. Nevertheless, further clinical runs are necessary to cover all possible cases of deadspace ratio changes. By incorporating an Expert System, the knowledge base may be easily extended as more clinical data becomes available.
~or the purpose of an even fuller understanding of the invention, the following description provides the pseudo code for programming the apparatus according to the invention. The program should be read in conjunction with Figure 6 which is a self-explanatory functional block diagram of the apparatus.
MAIN PROGRAM
System setup: Hardware setup and parameters initialization.
Repeat Timer: Keeping track of real-time, using each interrupt service form fixed-frequency AtoD conversion as W092/04865 PCT/AU91/0~35 - 2~92703 - 12 -time counter. Sets flags after each minute ("onemin"
flag) and five minutes ("fivemin" flag).
If "one min" flag is true, Ventrequest: Request data from ventilator by sending request codes to serial port. The first request is "SPD", send patient data.
FndCO2prod: Request calculate carbon dioxide production and mixed expired carbon dioxide for the minute.
Checkcomq: checking comm. queue. If queue is not empty, Readvent: Read characters received from ventilator.
If calculation above are satisfactory, Sbt_CO2calc: Request calculation of physiological parameters~and PaCO2 prediction.
If "fivemin" flag is true and calc. above are - satisfactory, InvokeExpert: Test if deadspace ratio changes.
InvokeControl: Control rules.
Checkkey: Check keyboard for keyhit. If Keyhit, Processkeyhit: "M" for marking of blood taken.
Entering of PaCO2, pH, HCO3.
"Q" to exit from program.
If hardware test failed, Safe-exit.: Disables all interrupts, turn off A/D conversion, and close all files before exiting .
If 0.5-4.0 seconds have elapsed, process data from queue:
Toscrn: Display on screen.
Tostore: Store in file.
FndCO2prod: ongoing CO2 production calc.
Sbt_CO2calc: Ongoing SBT calc.
Until exit from system SYSTEM SETUP
Initialize variables.
Initialize graphics (axes for plotting, etc.) S~JB~ ~ ~ ~ VTE SHEET
- 13 2~92 703 Hardware setup: Setting up lnterrupts for digital and analog interfacing.
HARDWARE SETUP
Setup a circular buffer (AtoDqueue) for storing real-time data.
Set up a circular buffer (Commqueue) for storing character strings received from serial port.
Program Analog to Digital Conversion card to convert at set frequency (lOOHz), and to generate an interrupt on completion of each conversion, for the first channel of three. (The three channels are the airway flow, pressure and capnograph signals.) Set and enable interrupt vector (Interrupt Service Routine: SetAtoD) for A/D card, to read analog flow and pressure from the ventilator, and capnograph waveform from the capnograph.
Set and enable interrupt vector (Interrupt Service Routine: SetComm) for serial port, to read digital data from ventilator.
INTERRUPT SERVICE ROUTINE: SetAtoD
Increment timing counter, for "Timer" routine.
Read converted data from port.
Request and read the other two channels. (The three channels are flow, pressure and capnograph waveform).
Put delay time between flow, pressure waveforms and the capnograph waveform to synchronize the signals.
Put data into the circular buffer (AtoDqueue).
INTERRUPT SERVICE ROUTINE: SetComm Put characters received in circular buffer (Commqueue).
TIMER
If "onemin" or "fivemin" flag has been set, clear it (Token removal to ensure that the token is passed around the real-time loop only once).
Checks timing counts. (Generated by ISR, SetAtoD).
If one minute ha elapsed, set "onemin" flag.
If five minutes have elapsed, set "fivemin" flag.
SUB~ JTE SHEET
W092/0~6~ PCT/AU91/00435 ~ ~ 3 ~ 7 ~) ~
FndCO2 Prod During ongoing calculations (by the data count), Repeat from queue head to tail, Read CO2 (mmHg), airway flow ~Lpm) and pressure signals (mmHg).
Calculate C~2 fraction:
CO2 fraction = CO2 / (PB -P~0 + pressure), where PB=760, P~0=47.
Correction for flow:
Flow(Lpm) = flow:
Compliance * (pressure-previous pressure) *
60/PTTOMS, where Compliance-5.17ml/mmHg, PTTOMS = 10.
If airway flow > +1.2 lpm (expiration phase), CO2flow =~ CO2flow + flow*CO2fraction.
(Integration of airway flow and CO2 fraction) Expvol = expvol + flow. (Calculation of expired volume in the breath) If request for a minute's COt production, CO2production = CO2flow * BTPStoSTPD *
PTTOMS/60.
where BTPStoSTPD=0.8262.
Expvol (ml) = expvol * BTPStoSTPD * PTTOMS/60.
Mixed-expired CO2(mmHg)=CO2 production*863*0.8262/Expvol.
Return READVENT
Read characters from circular buffer (Commqueue).
If carriage return is encountered (ie. end of message received), Check whether the heading of message is SPD (send patient data), SLM (send lung mechanics) or SVS
(send ventilator status).
For each message received, error checking by size of message, and whether various parameters read are within physiological range.
SUB~i 111 ~JTE SHEET
W092/~865 PCT/AU91/0043 - 15 ~ '20~270 3 If SPD is received, SLM will be requested.
If SLM is received, SVS will be requested.
If SVS is received, and if all data are acceptable, a flag will be set to indicate completion of ventilator requests.
(Parameters read from ventilator include : RR (rate), MV
(minute volume), MAP (mean air pressure), IE (inspiratory to expiratory ratio), VT (tidal vol), SMV (spontaneous MV), PAP (peak airway pressure), SRR (set rate), SVT (set VT), PIF (peak inspiratory pressure), PEEP (positive end expiratory pressure), DMC (Dynamic Compliance), DMR
(Dynamic Resistance)).
Sbt CO2calc If ongoing calculation, For each breath, if flow <-1.2Lpm (inspiration phase), Tinsp (inspiratory time) is counted.
For each breath, if flow >+1.2Lpm (expiration), Correct for compliance flow.
Calculate tidal volume(Vt):
Expvol(ml) = expvol + (flow*PTTOMS/1000).
Plot Single Breath Co2 Expiration curve (airway CO2 (mmHg) vs expvol(ml)).
Calculate gradient of airway CO2 vs expvol.
Record the maximum inflection point of CO2 vs expvol;
This is the airway deadspace, VD
At end of expiration (flowc-1.2Lpm), Reject data from the breath if waveform is unphysiological (Less than 50 data points, or maximum inflexion point is not found).
Determine end-tidal Co2, the maximum airway CO2.
Calculate the plateau slope of CO2 vs expvol.
Calculate the area under the Single Breath CO2 (area X), by summation.
Parameters calculated for this breath are summed with parameters from previous breaths within a SUB~ 111 ~JTE SHE~T
W092/0~65 PCT/AU91/0043S
2~92703 minute. The parameters are: the number of breaths, areaX, VD~W~y~ tidal volume (VT), end-tidal CO2 (ETCO2), plateau phase slope, Tinsp and number of rejected waveforms.
If request for a CO2 prediction, If arterial CO2 sample is drawn (marked) but not available yet, The minute's parameters are kept in a buffer.
If arterial CO2 is available, An average for all parameters over the last minute is calculated. (The average value of each parameter is the summation/total number of breaths.) From the average, the following calculations are done:
V,~(alveolar tidal vol) = VT ~ VD~W.~-PE*CO2 (bag mixed expired CO2) = area X/VT~.
PEb"CO2 (bag mixed expired CO2) co2prod*863/ (VT*f) 2 0 PEb-~CO2 = PEb~CO2 * VT/VT
PiCo2 - PECO2 = PEb-~CO2.
If PaCO2 is new, Calculate new deadspace ratio:
VD~ (alveolar deadspace) =
VT~(PaCO2)/(PacO2-pico2)-Alvcon (deadspace ratio) = VD~/VT~
VDphy(physiological deadspace) = VD~ + ADU~-Y -Estimated PCO2(EPaCO2) = (PECO2-AlvconPiCO2)/(l-Alvcon).
InvokeEx~ert: Rules to check if deadspace ratio has changed.
(Parameters needed are: MV, ETCO2, EPaCO2, CO2prod, slope, DMC, DMR, Tinsp, PEEP, PAP).
Whenever the rules below are triggered three times consecutively, a warning is generated (Note that SUB~i 111 ~JTE SHEET
W092/~86~ PCT/AU91/0043~
the parameters are compared with the values obtained from the most recent blood gas results):
If MV increases by 800 ml or more and ETC02 does not drop by at least 2 mmHg.
If MV decreases by 800 ml or more and ETC02 does not increase by at least 2 mmHg.
If MV increases by 800 ml or more and EPaCO2 does not drop by at least 2 mmHg.
If MV decreases by 800 ml or more and EPaCO2 does not increase by at least 2 mmHg.
If MV increases by 800 ml or more and C02prod does not increase by at least 20 ml.
If MV decreases by 800 ml or more and C02prod does not decrease by at least 20 ml.
If slope changes by more than 0.5 mmHg/ml.
IF DMR changes by more than lO cmH20/L/s.
IF DMC changes by more than lO ml/cmH20.
If Tinsp changes by more than 0.5 s.
If PAP changes by more than lO cmH20.
If previous PEEP is less than lO cmH20 and changes by more than 5 cmH20.
If previous PEEP is equal or more than lO cmH20 and changes by more than 2 cmH20.
InvokeControl: Rules for ventilator control.
(Parameters needed are:
Entered from blood gas results: pH, HC03, settings limits (I:E ratio minimum, rate limits, volume limits, peak pressure limit).
From ventilator requests: RR, MV, MAP, IE, VT, SMV, PAP, SRR, SVT, PIF, PEEP, DMC, DMR.
From Calculations: Vdphy, EPaC02.) If new blood test result is available, calculate new C~2 setpoint:
If (pH~7.36) or (pH>7.44) CO2 setpoint = l.6706*HCO3 Calculate alveolar minute volume needed (AMVneeded);
SUB~ TE SHEEl-W092/0486~ PCT/AU91/0043~
~9~703 - 18 -AMV (Alveolar minute volume(ml)) = (MV*l000-RR*VDphy).
AMVneeded = EPaCO2 * AMV/CO2 setpoint.
Correct for spontaneous breathing; If (SMV>O) and (RR~SRR) RRspont (Spontaneous rate) = SRR-RR.
AMVneeded = AMVneeded - (SMV*l000 RRspont*VDphy).
Control.
Control Calculate an initial tidal volume needed using current frequency, to produce the required minute volume:
newVT = (AMVneeded/RR) + VDphy.
If PAP>PAP limit, Repeat - Check the proposed VT & RR to rest if their limits have been exceeded (CheckVT, CheckRR);
Results of these checks are entered into the look-up table. Calculate VT & RR using look-up table l; Results from look-up table decides whether calculated settings are acceptable.
Until the result from look-up table is either "Implement" or "Impossible".
else Repeat Check VT & RR if limits exceeded.
Calculate VT & RR using look-up table 2.
Until the result is either "Implement" or "Impossible".
Checkin~ VT & RR
CheckVT:
If VT>maximumVT, result is "Not Increase".
If VT<minimumVT, result is "Not Decrease".
Otherwise result is "OK".
Check RR:
SUB~ 111 ~JTE SHEET
W092/0~65 PCT/AU91/00435 - - 19 2~927Q3 If RR>maximumRR, result is "Not Increase RR".
If RR<minimumRR, result is "Not Decrease RR".
Otherwise result is "OK".
Looku~ tables After doing the checks for VT & RR, the VT & RR results are used with the appropriate look-up table to determine the next calculation.
Lookup Table 1 - VT result OK Not Increase Not Decrease RR result OK Implement Drop V Inc V
Not increase DropRR Impossible Inc V
Not Decrease Inc RR Drop V Impossible Lookup Table 2 VT result OK Not increase Not Decrease RR result OK Implement Drop V Impossible Not Increase Impossible Impossible Impossible 20 Not Decrease Drop V Drop V Impossible If result is "Inc V", increase VT by 50 ml.
If result is "Drop V, decrease VT by 50ml.
If VT has changed, calculate new RR for the required minute volume (AMVneeded):
new RR = AMVneeded/(VT - VDphy).
If result is "Inc RR", increase RR by 1 BPM.
If result is "Drop RR", decrease RR by 1 BPM.
If RR has changed, calculate new VT for the required AMVneeded:
new VT = (AMVneeded/RR) + VDphy.
If result from the look-up tables is "Implement", If (IE<minimumIE) S~JB~ 1 l l UTE SHEE~
W O 92/0486~ P(~rJAU91/0043 ~ o g 2 7 ~ 3 - 20 -If (new RR is bigger or equal to the current setting) Increase PAF by 10 LPM. (Ensure IE ratio is above the minimum by increasing peak ~ir flow).
Implement the new VT & RR.
If result is "Impossible", A warning alarm is generated to indicate inability to implement required settings.
It will be apparent from the foregoing that while particular forms of the invention have been illustrated and described, various modifications can be made without departing from the spirit and scope of the invention.
Accordingly, it is not intended that the invention be limited, except as by the appended claims.
SUB~ 111 ~JTE SHEEl-
If (2) or (3) cannot be satisfied, keep VT constant and increase f such that -(a) f is not smaller than 10 bpm.
(b) f is not bigger than 20 bpm. (and not less than 10 bpm.) (c) Inspiratory to expiratory ratio (I:E) is smaller than 1:2.
If (b) or (c) is exceeded, Peak air flow (PAF) should be increased.
If the required minute volume cannot be achieved without exceeding the limits in any one of VT/f/PAP/mean pressure/PAF/I:E, a warning message will be displayed to alert the clinician.
As is evident above, the system of the invention is implemented, according to one embodiment, on a PC-AT
computer. Analogue flow and pressure signals from the Puritan-Bennett 7200 ventilator and airwave CO2 signals from the HP-78356 capnograph are analogue-to-digital converted and processed in real time using the computer.
Each breath is checked to reject unphysiological waveforms, such as incomplete spontaneous breaths, before further processing. A PaCO2 estimate is calculated every minute and the decision rules are invoked.
Tests have been performed to verify all calculations made in formulating the decision rules. C02 SUBSTITUTE ~;HEET
production and mixed-expired CO2 were tested against the Douglas bag method. Airway deadspace was checked by introducing a known deadspace into the ventilator circuit. Correct,ons had to be made to account for airway tubing compliance, time delay between the flow and capnograph signal, and rebreathing. To test the accuracy of PaCO2 estimation, clinical trials were carried out on ICU patients. For each patient, tidal volume and ventilation rate were changed in different combinations to a maximum of 30% of the initial settings. After each change and a stabilization period of about 10 minutes, a blood sample was drawn to check the estimation. Each clinical experiment involved 6-8 manipulations, over 90 minutes.
To identify the factors and the degree that they affect the alveolar deadspace ratio, specific procedures are incorporated into the clinical experiments to change the deadspace. Posture of the patient is changed by tuning the patient or inclining of the bed. Another procedure has been to administer bronchodilators.
Various measurable parameters are recorded during the experiments for correlation with deadspace changes.
These include airway compliance and resistance, peak airway pressure, peak air flow, inspiratory time, positive end-expiratory pressure (PEEP), inspiratory to expiratory ratio (I:E), slope of the CO2 versus expired-volume waveform, end-tidal CO2 and SaO2.
The test results show reliable estimation (+ 5 mmHg) of PaCO2, even when deadspace ratio changed by up to 30% of the initial value. This indicates that the estimator is robust to some changes in the deadspace ratio.
Test results also showed that deadspace ratio change can be expected when alveolar tidal volume and ~5 frequency changes are not followed by expected changes in end-tidal CO2, estimated PaCO2 or CO2 production. Results from a trial are presented in Fig. S. At point A, the SUBSTITUTE SHEET
increase in alveolar tidal volume and ventilation rate product (alveolar minute-volume) is not followed by a drop in both end-tidal CO2 and estimated PaCO2, indicating a blood test is needed. At point B, alveolar minute-5 volume decrease is not followed by an increase in end-tidal CO2. In each case, the new estimation system correctly identifies the deadspace ratio change and estimates PaCO2 reliably, compared to using the traditional method based on a constant arterial - end tidal difference.
Changes to compliance and resistance, peak airway pressure, peak flow, SaO2 and I:E should indicate a change in the deadspace ratio but more results are needed before these relationships can be quantified.
The results show that the PaCO2 estimator is sufficiently robust to permit continuous estimation for a wide range of ventilator settings. For large deadspace changes, the experimentally derived rules can be relied upon to signal for a blood gas test. Nevertheless, further clinical runs are necessary to cover all possible cases of deadspace ratio changes. By incorporating an Expert System, the knowledge base may be easily extended as more clinical data becomes available.
~or the purpose of an even fuller understanding of the invention, the following description provides the pseudo code for programming the apparatus according to the invention. The program should be read in conjunction with Figure 6 which is a self-explanatory functional block diagram of the apparatus.
MAIN PROGRAM
System setup: Hardware setup and parameters initialization.
Repeat Timer: Keeping track of real-time, using each interrupt service form fixed-frequency AtoD conversion as W092/04865 PCT/AU91/0~35 - 2~92703 - 12 -time counter. Sets flags after each minute ("onemin"
flag) and five minutes ("fivemin" flag).
If "one min" flag is true, Ventrequest: Request data from ventilator by sending request codes to serial port. The first request is "SPD", send patient data.
FndCO2prod: Request calculate carbon dioxide production and mixed expired carbon dioxide for the minute.
Checkcomq: checking comm. queue. If queue is not empty, Readvent: Read characters received from ventilator.
If calculation above are satisfactory, Sbt_CO2calc: Request calculation of physiological parameters~and PaCO2 prediction.
If "fivemin" flag is true and calc. above are - satisfactory, InvokeExpert: Test if deadspace ratio changes.
InvokeControl: Control rules.
Checkkey: Check keyboard for keyhit. If Keyhit, Processkeyhit: "M" for marking of blood taken.
Entering of PaCO2, pH, HCO3.
"Q" to exit from program.
If hardware test failed, Safe-exit.: Disables all interrupts, turn off A/D conversion, and close all files before exiting .
If 0.5-4.0 seconds have elapsed, process data from queue:
Toscrn: Display on screen.
Tostore: Store in file.
FndCO2prod: ongoing CO2 production calc.
Sbt_CO2calc: Ongoing SBT calc.
Until exit from system SYSTEM SETUP
Initialize variables.
Initialize graphics (axes for plotting, etc.) S~JB~ ~ ~ ~ VTE SHEET
- 13 2~92 703 Hardware setup: Setting up lnterrupts for digital and analog interfacing.
HARDWARE SETUP
Setup a circular buffer (AtoDqueue) for storing real-time data.
Set up a circular buffer (Commqueue) for storing character strings received from serial port.
Program Analog to Digital Conversion card to convert at set frequency (lOOHz), and to generate an interrupt on completion of each conversion, for the first channel of three. (The three channels are the airway flow, pressure and capnograph signals.) Set and enable interrupt vector (Interrupt Service Routine: SetAtoD) for A/D card, to read analog flow and pressure from the ventilator, and capnograph waveform from the capnograph.
Set and enable interrupt vector (Interrupt Service Routine: SetComm) for serial port, to read digital data from ventilator.
INTERRUPT SERVICE ROUTINE: SetAtoD
Increment timing counter, for "Timer" routine.
Read converted data from port.
Request and read the other two channels. (The three channels are flow, pressure and capnograph waveform).
Put delay time between flow, pressure waveforms and the capnograph waveform to synchronize the signals.
Put data into the circular buffer (AtoDqueue).
INTERRUPT SERVICE ROUTINE: SetComm Put characters received in circular buffer (Commqueue).
TIMER
If "onemin" or "fivemin" flag has been set, clear it (Token removal to ensure that the token is passed around the real-time loop only once).
Checks timing counts. (Generated by ISR, SetAtoD).
If one minute ha elapsed, set "onemin" flag.
If five minutes have elapsed, set "fivemin" flag.
SUB~ JTE SHEET
W092/0~6~ PCT/AU91/00435 ~ ~ 3 ~ 7 ~) ~
FndCO2 Prod During ongoing calculations (by the data count), Repeat from queue head to tail, Read CO2 (mmHg), airway flow ~Lpm) and pressure signals (mmHg).
Calculate C~2 fraction:
CO2 fraction = CO2 / (PB -P~0 + pressure), where PB=760, P~0=47.
Correction for flow:
Flow(Lpm) = flow:
Compliance * (pressure-previous pressure) *
60/PTTOMS, where Compliance-5.17ml/mmHg, PTTOMS = 10.
If airway flow > +1.2 lpm (expiration phase), CO2flow =~ CO2flow + flow*CO2fraction.
(Integration of airway flow and CO2 fraction) Expvol = expvol + flow. (Calculation of expired volume in the breath) If request for a minute's COt production, CO2production = CO2flow * BTPStoSTPD *
PTTOMS/60.
where BTPStoSTPD=0.8262.
Expvol (ml) = expvol * BTPStoSTPD * PTTOMS/60.
Mixed-expired CO2(mmHg)=CO2 production*863*0.8262/Expvol.
Return READVENT
Read characters from circular buffer (Commqueue).
If carriage return is encountered (ie. end of message received), Check whether the heading of message is SPD (send patient data), SLM (send lung mechanics) or SVS
(send ventilator status).
For each message received, error checking by size of message, and whether various parameters read are within physiological range.
SUB~i 111 ~JTE SHEET
W092/~865 PCT/AU91/0043 - 15 ~ '20~270 3 If SPD is received, SLM will be requested.
If SLM is received, SVS will be requested.
If SVS is received, and if all data are acceptable, a flag will be set to indicate completion of ventilator requests.
(Parameters read from ventilator include : RR (rate), MV
(minute volume), MAP (mean air pressure), IE (inspiratory to expiratory ratio), VT (tidal vol), SMV (spontaneous MV), PAP (peak airway pressure), SRR (set rate), SVT (set VT), PIF (peak inspiratory pressure), PEEP (positive end expiratory pressure), DMC (Dynamic Compliance), DMR
(Dynamic Resistance)).
Sbt CO2calc If ongoing calculation, For each breath, if flow <-1.2Lpm (inspiration phase), Tinsp (inspiratory time) is counted.
For each breath, if flow >+1.2Lpm (expiration), Correct for compliance flow.
Calculate tidal volume(Vt):
Expvol(ml) = expvol + (flow*PTTOMS/1000).
Plot Single Breath Co2 Expiration curve (airway CO2 (mmHg) vs expvol(ml)).
Calculate gradient of airway CO2 vs expvol.
Record the maximum inflection point of CO2 vs expvol;
This is the airway deadspace, VD
At end of expiration (flowc-1.2Lpm), Reject data from the breath if waveform is unphysiological (Less than 50 data points, or maximum inflexion point is not found).
Determine end-tidal Co2, the maximum airway CO2.
Calculate the plateau slope of CO2 vs expvol.
Calculate the area under the Single Breath CO2 (area X), by summation.
Parameters calculated for this breath are summed with parameters from previous breaths within a SUB~ 111 ~JTE SHE~T
W092/0~65 PCT/AU91/0043S
2~92703 minute. The parameters are: the number of breaths, areaX, VD~W~y~ tidal volume (VT), end-tidal CO2 (ETCO2), plateau phase slope, Tinsp and number of rejected waveforms.
If request for a CO2 prediction, If arterial CO2 sample is drawn (marked) but not available yet, The minute's parameters are kept in a buffer.
If arterial CO2 is available, An average for all parameters over the last minute is calculated. (The average value of each parameter is the summation/total number of breaths.) From the average, the following calculations are done:
V,~(alveolar tidal vol) = VT ~ VD~W.~-PE*CO2 (bag mixed expired CO2) = area X/VT~.
PEb"CO2 (bag mixed expired CO2) co2prod*863/ (VT*f) 2 0 PEb-~CO2 = PEb~CO2 * VT/VT
PiCo2 - PECO2 = PEb-~CO2.
If PaCO2 is new, Calculate new deadspace ratio:
VD~ (alveolar deadspace) =
VT~(PaCO2)/(PacO2-pico2)-Alvcon (deadspace ratio) = VD~/VT~
VDphy(physiological deadspace) = VD~ + ADU~-Y -Estimated PCO2(EPaCO2) = (PECO2-AlvconPiCO2)/(l-Alvcon).
InvokeEx~ert: Rules to check if deadspace ratio has changed.
(Parameters needed are: MV, ETCO2, EPaCO2, CO2prod, slope, DMC, DMR, Tinsp, PEEP, PAP).
Whenever the rules below are triggered three times consecutively, a warning is generated (Note that SUB~i 111 ~JTE SHEET
W092/~86~ PCT/AU91/0043~
the parameters are compared with the values obtained from the most recent blood gas results):
If MV increases by 800 ml or more and ETC02 does not drop by at least 2 mmHg.
If MV decreases by 800 ml or more and ETC02 does not increase by at least 2 mmHg.
If MV increases by 800 ml or more and EPaCO2 does not drop by at least 2 mmHg.
If MV decreases by 800 ml or more and EPaCO2 does not increase by at least 2 mmHg.
If MV increases by 800 ml or more and C02prod does not increase by at least 20 ml.
If MV decreases by 800 ml or more and C02prod does not decrease by at least 20 ml.
If slope changes by more than 0.5 mmHg/ml.
IF DMR changes by more than lO cmH20/L/s.
IF DMC changes by more than lO ml/cmH20.
If Tinsp changes by more than 0.5 s.
If PAP changes by more than lO cmH20.
If previous PEEP is less than lO cmH20 and changes by more than 5 cmH20.
If previous PEEP is equal or more than lO cmH20 and changes by more than 2 cmH20.
InvokeControl: Rules for ventilator control.
(Parameters needed are:
Entered from blood gas results: pH, HC03, settings limits (I:E ratio minimum, rate limits, volume limits, peak pressure limit).
From ventilator requests: RR, MV, MAP, IE, VT, SMV, PAP, SRR, SVT, PIF, PEEP, DMC, DMR.
From Calculations: Vdphy, EPaC02.) If new blood test result is available, calculate new C~2 setpoint:
If (pH~7.36) or (pH>7.44) CO2 setpoint = l.6706*HCO3 Calculate alveolar minute volume needed (AMVneeded);
SUB~ TE SHEEl-W092/0486~ PCT/AU91/0043~
~9~703 - 18 -AMV (Alveolar minute volume(ml)) = (MV*l000-RR*VDphy).
AMVneeded = EPaCO2 * AMV/CO2 setpoint.
Correct for spontaneous breathing; If (SMV>O) and (RR~SRR) RRspont (Spontaneous rate) = SRR-RR.
AMVneeded = AMVneeded - (SMV*l000 RRspont*VDphy).
Control.
Control Calculate an initial tidal volume needed using current frequency, to produce the required minute volume:
newVT = (AMVneeded/RR) + VDphy.
If PAP>PAP limit, Repeat - Check the proposed VT & RR to rest if their limits have been exceeded (CheckVT, CheckRR);
Results of these checks are entered into the look-up table. Calculate VT & RR using look-up table l; Results from look-up table decides whether calculated settings are acceptable.
Until the result from look-up table is either "Implement" or "Impossible".
else Repeat Check VT & RR if limits exceeded.
Calculate VT & RR using look-up table 2.
Until the result is either "Implement" or "Impossible".
Checkin~ VT & RR
CheckVT:
If VT>maximumVT, result is "Not Increase".
If VT<minimumVT, result is "Not Decrease".
Otherwise result is "OK".
Check RR:
SUB~ 111 ~JTE SHEET
W092/0~65 PCT/AU91/00435 - - 19 2~927Q3 If RR>maximumRR, result is "Not Increase RR".
If RR<minimumRR, result is "Not Decrease RR".
Otherwise result is "OK".
Looku~ tables After doing the checks for VT & RR, the VT & RR results are used with the appropriate look-up table to determine the next calculation.
Lookup Table 1 - VT result OK Not Increase Not Decrease RR result OK Implement Drop V Inc V
Not increase DropRR Impossible Inc V
Not Decrease Inc RR Drop V Impossible Lookup Table 2 VT result OK Not increase Not Decrease RR result OK Implement Drop V Impossible Not Increase Impossible Impossible Impossible 20 Not Decrease Drop V Drop V Impossible If result is "Inc V", increase VT by 50 ml.
If result is "Drop V, decrease VT by 50ml.
If VT has changed, calculate new RR for the required minute volume (AMVneeded):
new RR = AMVneeded/(VT - VDphy).
If result is "Inc RR", increase RR by 1 BPM.
If result is "Drop RR", decrease RR by 1 BPM.
If RR has changed, calculate new VT for the required AMVneeded:
new VT = (AMVneeded/RR) + VDphy.
If result from the look-up tables is "Implement", If (IE<minimumIE) S~JB~ 1 l l UTE SHEE~
W O 92/0486~ P(~rJAU91/0043 ~ o g 2 7 ~ 3 - 20 -If (new RR is bigger or equal to the current setting) Increase PAF by 10 LPM. (Ensure IE ratio is above the minimum by increasing peak ~ir flow).
Implement the new VT & RR.
If result is "Impossible", A warning alarm is generated to indicate inability to implement required settings.
It will be apparent from the foregoing that while particular forms of the invention have been illustrated and described, various modifications can be made without departing from the spirit and scope of the invention.
Accordingly, it is not intended that the invention be limited, except as by the appended claims.
SUB~ 111 ~JTE SHEEl-
Claims (12)
1. A method of continuously and non-invasively monitoring arterial blood CO2 partial pressure of artificially ventilated patients by monitoring a patient's breath, and determining PaCO2 based upon a determination of a deadspace ratio, comprising the steps of:
a) continuously monitoring measurable parameters of a patient's breath;
b) measuring the PaCO2 from a blood sample of the patient and obtaining an input value;
calculating the deadspace ratio using the patient's breath parameters and said input value; and c) continuously determining PaCO2 based on the assumption that the deadspace ratio subsequently remains constant.
a) continuously monitoring measurable parameters of a patient's breath;
b) measuring the PaCO2 from a blood sample of the patient and obtaining an input value;
calculating the deadspace ratio using the patient's breath parameters and said input value; and c) continuously determining PaCO2 based on the assumption that the deadspace ratio subsequently remains constant.
2. The method of claim 1, wherein said step of continuously monitoring measurable parameters of a patient's breath comprises monitoring mixed-expired CO2 partial pressure, inspired CO2 partial pressure, and alveolar tidal volume.
3. The method of Claim 2, wherein said step of continuously monitoring measurable parameters of a patient's breath further comprises monitoring alveolar deadspace.
4. The method of Claim 1, wherein said step of continuously determining PaCO2 is based upon the equation VDALV/VTALV = (PaCO2-PE~CO2) / (PaCO2 - PiCO2) where VDALV is the alveolar deadspace, VTALV is the alveolar tidal volume, PE~CO2 is the mixed-expired CO2 partial pressure from the alveolar tidal volume, and PiCO2 is inspired CO2 partial pressure.
5. The method of Claim 1, further comprising the steps of identifying the onset of changes in the deadspace ratio by decision rules obtained from other measurable data; and determining a new deadspace ratio from the patient's breath parameters and a further input value of PaCO2 from the patient's blood sample.
6. The method of Claim 5, wherein said step of identifying the onset of changes in the deadspace ratio by decision rules obtained from other measurable data comprises monitoring parameters related to lung mechanics and changes in CO2 production as measured by PE*CO2 partial pressure from the alveolar tidal volume.
7. The method of Claim 1, further comprising the step of adjusting patient ventilation based on the determined value of PaCO2.
8. An apparatus for continuously and non-invasively monitoring arterial blood CO2 partial pressure of artificially ventilated patients, comprising:
a) means for monitoring continuously measurable parameters relevant to a patient's breath and providing data relating thereto;
b) means for obtaining an input value corresponding to the PaCO2 of a blood sample from the patient;
means for determining a deadspace ratio, connected to receive said input value and the patient's breath parameter data, wherein said means for determining calculates the deadspace ratio from the input value and the patient's breath parameter data; and c) means for continuously determining PaCO2 based on the deadspace ratio, and the assumption that the deadspace ratio remains subsequently constant.
a) means for monitoring continuously measurable parameters relevant to a patient's breath and providing data relating thereto;
b) means for obtaining an input value corresponding to the PaCO2 of a blood sample from the patient;
means for determining a deadspace ratio, connected to receive said input value and the patient's breath parameter data, wherein said means for determining calculates the deadspace ratio from the input value and the patient's breath parameter data; and c) means for continuously determining PaCO2 based on the deadspace ratio, and the assumption that the deadspace ratio remains subsequently constant.
9. The apparatus of Claim 8, wherein said means for monitoring continuously measurable parameters relevant to a patient's breath and providing data relating thereto comprises a capnograph.
10. The apparatus of Claim 8, wherein said means for determining a deadspace ratio comprises microprocessor.
11. The apparatus of Claim 8, further including means for identifying the onset of changes in the deadspace ratio to thereby signal the need for a further blood sample to re-calculate the deadspace ratio, based upon decision rules.
12. The apparatus of Claim 8, further including means for controlling the operation of a mechanical ventilator based upon the values of PaCO2 determined by the apparatus.
Applications Claiming Priority (2)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| AUPK2403 | 1990-09-19 | ||
| AUPK240390 | 1990-09-19 |
Publications (2)
| Publication Number | Publication Date |
|---|---|
| CA2092703A1 CA2092703A1 (en) | 1992-03-20 |
| CA2092703C true CA2092703C (en) | 1998-06-30 |
Family
ID=3774966
Family Applications (1)
| Application Number | Title | Priority Date | Filing Date |
|---|---|---|---|
| CA002092703A Expired - Lifetime CA2092703C (en) | 1990-09-19 | 1991-09-19 | Arterial co2 monitor and closed loop controller |
Country Status (6)
| Country | Link |
|---|---|
| US (1) | US5402796A (en) |
| EP (1) | EP0549685B1 (en) |
| JP (1) | JP2688453B2 (en) |
| CA (1) | CA2092703C (en) |
| DE (1) | DE69131836T2 (en) |
| WO (1) | WO1992004865A1 (en) |
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-
1991
- 1991-09-19 EP EP91917046A patent/EP0549685B1/en not_active Expired - Lifetime
- 1991-09-19 CA CA002092703A patent/CA2092703C/en not_active Expired - Lifetime
- 1991-09-19 US US08/030,123 patent/US5402796A/en not_active Expired - Lifetime
- 1991-09-19 DE DE69131836T patent/DE69131836T2/en not_active Expired - Lifetime
- 1991-09-19 JP JP3517312A patent/JP2688453B2/en not_active Expired - Fee Related
- 1991-09-19 WO PCT/AU1991/000435 patent/WO1992004865A1/en active IP Right Grant
Also Published As
| Publication number | Publication date |
|---|---|
| EP0549685A4 (en) | 1997-12-29 |
| JPH06502090A (en) | 1994-03-10 |
| US5402796A (en) | 1995-04-04 |
| EP0549685B1 (en) | 1999-12-08 |
| DE69131836D1 (en) | 2000-01-13 |
| EP0549685A1 (en) | 1993-07-07 |
| WO1992004865A1 (en) | 1992-04-02 |
| CA2092703A1 (en) | 1992-03-20 |
| DE69131836T2 (en) | 2000-07-27 |
| JP2688453B2 (en) | 1997-12-10 |
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